Building Trust, Preventing Trauma: Addressing Maternal Near Misses

When discussing maternal health in the United States, the focus often leans toward mortality rates — rightfully so, given the alarming increase in maternal deaths in recent years. However, an equally urgent and often overlooked issue is the concept of a maternal near miss. The World Health Organization (WHO) defines a maternal near miss, also referred to as severe acute maternal morbidity, as an occurrence when a person experiences life-threatening complications during pregnancy, childbirth, or within the first six weeks of the postpartum period but survives.1 This survival is often due to factors such as last-minute medical intervention, sheer determination, or chance. These incidents are not merely close calls; they serve as significant warning signs of systemic failures. 

Maternal near misses typically stem from severe complications such as embolism, cardiac events, hemorrhage, sepsis, and hypertensive disorders like preeclampsia and eclampsia.2 According to the Centers for Disease Control and Prevention, for every maternal death in the U.S., there are nearly 70 near-miss events — roughly 50,000 each year.3 These numbers reflect individual health conditions and highlight structural problems within our maternal health care system. Delays in diagnosis, misinterpretation of symptoms, and inadequate responses from health care providers often escalate manageable conditions into life-threatening emergencies.4

The risk of experiencing a near miss in maternal health is not equally distributed among all demographic groups. Black individuals are nearly three times more likely than their white counterparts to suffer from maternal near misses.5 Indigenous people, individuals with lower incomes, members of the LGBTQ+ community, uninsured people, and those living in rural areas also face disproportionate maternal health risks.6 7 Factors such as age, socioeconomic status, and geographic isolation exacerbate these disparities.7  

The Role of Trust and Trustworthiness     

At the heart of many maternal near misses lies a deeper issue: the fragile nature of trust between patients and the health care system. Trust isn’t just about how much confidence a patient has in a provider; it’s about how trustworthy the provider, and the system itself, proves to be.8 In the polling brief Trustworthy Care from Conception to Cradle: A Key Ingredient for Maternal Health Equity, the AAMC Center for Health Justice explored trust in maternal health care across the perinatal period — pregnancy, labor and delivery, and the postpartum period. The results of the poll revealed that the majority of individuals from a nationally representative sample of those who have ever given birth (ages 18+) reported high levels of trust in their health care team during pregnancy, labor and delivery, and the postpartum period.  

However, trust can erode, especially in the face of severe complications or when concerns are not taken seriously.9 The poll also found a decline in trust during the postpartum period among younger adults — Gen Zers and millennials — and American Indian/Alaska Native, Asian, Black or African American, Hispanic or Latino, and Native Hawaiian or Pacific Islander adults. These same groups also reported higher rates of negative experiences during labor and delivery, including being ignored, dismissed, coerced, or medically harmed. For many individuals, experiences of mistreatment, being dismissed, being gaslit, or subjected to biased care can convert initial trust into lasting mistrust. When life-threatening pregnancy complications are met with medically inadequate or culturally incompetent care, it reinforces a cycle in which trust is not only lost but replaced with fear and skepticism.9 In these moments, trust is not just tested — it is often broken. Trustworthiness in maternal health care means showing up for patients consistently, listening carefully to their concerns, and delivering culturally competent, respectful care.10  

Reducing Maternal Near Misses Through Trustworthy Systems 

In a country as medically advanced as the U.S., one might expect childbirth to be a consistently safe experience. Yet for far too many, especially Black, Indigenous, low-income, and LGBTQ+ individuals, it is marked by complications and uncertainty. An important question to address is how to prevent maternal near misses and the medical mistrust that often accompanies them. 

First, health care institutions must prioritize patient-centered care that recognizes the unique needs of diverse communities.11 Listening to patients, validating their experiences, and being proactive rather than reactive are foundational steps. Second, there needs to be systemic accountability. Maternal mortality review boards offer a powerful tool for identifying medical errors and the contribution of social and systemic factors to poor outcomes.4 Building on this, the WHO developed a maternal near-miss approach to help health systems identify and learn from cases where individuals survived life-threatening complications, providing further insight into gaps in care, and opportunities for prevention.12 Finally, community-based programs offer a blueprint for what trustworthiness can look like in action. Doulas, midwives, and community health workers — especially those who share cultural and/or racial backgrounds with their clients — act as trusted links between patients and the health care system.13 14 Their presence improves patient satisfaction and has been shown to reduce the likelihood of complications, including near misses.15 By creating a trustworthy system, we can reduce near misses and redefine what it means to provide effective and respectful maternity care.