In the U.S. between 2020 and 2024, just over 18 million babies were born, at a rate that was down on figures from previous decades. But what does the data tell us about comparative birth safety in the U.S. since the 1980s?
This Birth Injury Lawyers Group campaign uses five decades of CDC and NCHS statistics to compare birth in America from the 1980s to the present day. We’ll consider the key measures of a safe start (infant and neonatal mortality, preterm birth, low birthweight, and delivery method/maternal mortality) to see how things have improved or deteriorated.
First, let’s look at how birth rates have changed since 1980.
Births in the U.S.: From 1980 to the Present Day
America’s fertility rate has dropped by over a fifth since 1980. The general fertility rate (births per 1,000 women aged between 15 and 44) was 68.4 in 1980 and averaged 66.8 throughout the decade. It then averaged 66.3 in the 1990s and 66.7 in the 2000s. Yet a real shift occurred after 2007.
In the 2010s, the rate averaged 61.8, 7.3% below 2000s levels, then fell again to 55.7 by 2020. The average so far in the 2020s (2020 to 2024 figures) is 55.3, with a record-low of 53.8 in 2024, which is 21% below 1980 levels and 24% below the 1990 peak (70.9).
The crude birth rate has been subject to an even steeper decline, falling from 15.9 births per 1,000 people in 1980 (and the 1990 peak of 16.7) to 10.7 in 2024, a 33% drop. Decade averages fell from 15.8 in the 1980s to 15.1 in the 1990s, 14.1 in the 2000s, 12.3 in the 2010s, and finally 10.9 in the 2020s.
For a while, raw birth count levels masked the per-capita decline. The U.S. recorded 176.1 million births between 1980 and 2024. In 1980, there were 3,612,258 births; by 1989, the number was 4,040,958 (the first time over four million births had been recorded since 1964), and the number rose again in 1990 to 4,158,212.
Despite a dip to 3,880,894 in 1997, the rate then rose 11% to an all-time peak of 4,316,233 in 2007. Every year between 2000 and 2009 was subject to birth figures in excess of four million, with decade totals increasing from 37.5 million in the 1980s to 39.9 million in the 1990s and 41.4 million in the 2000s (a 10% increase over 1980s numbers, despite little change to the per-capita rate).
Births then fell to 3,999,386 in 2010 and remained at levels between 3.93 and 3.99 million up to 2016 before they fell once again. Overall, the 2010s saw 39.1 million births, 5% fewer than during the 2000s, with every year from 2017 onwards subject to a fertility rate below 61.
The pandemic meant births fell another 3.6% between 2019 and 2020, to 3,613,647, the lowest count since 1980. Birth numbers rebounded slightly in 2021 and 2022 (to 3,664,292 and 3,667,758), then fell to another modern low in 2023 (3,596,017) before rising 1% to 3,628,934 in 2024. Nonetheless, that figure is still 13% below 1990 levels and 16% below the 2007 peak.
The current decade is set to feature the fewest births in over 40 years, with an average of 3.63 million births a year (compared to 4.14 million in the 2000s), which represents a 12% decline.
But declining numbers are one thing: what about delivery methods, and how that affects child safety?
Delivery Methods, Including Cesareans
How babies are delivered in the U.S. has undergone significant change over the period in question, with key implications for child safety.
In 1980, 16.5% of U.S. births were cesarean, 83.5% vaginal. The country’s first surgical boom had begun, with the cesarean share subsequently climbing significantly over the next eight years to 24.7% by 1988, then the highest rate recorded by a developed nation.
By way of corrective response, hospitals promoted vaginal birth after cesarean (VBAC) throughout the 1990s. The VBAC rate rose from 3.4% in 1980 to 28.3% in 1996, while the overall cesarean rate fell to a modern low of 20.7%. Yet this cesarean reversal lasted just one decade.
From 1997, the cesarean rate rose every year for 13 years, and reached an all-time peak of 32.9% in 2009 (which was a 44% increase on 1997 figures). Meanwhile, the VBAC rate collapsed from 28.3% to 9.2% by 2004 as concerns around liability led some hospitals to ban the practice.
Since then, the cesarean rate has held, averaging 32.3% in the 2010s and 32.1% (so far) in the 2020s (though reaching 32.4% in 2024). VBAC has also recovered to a 15.5% rate, its highest level since 2000.
The rise in cesarean births between 1997 and 2009 directly overlaps with the peak in preterm births in 2006 and the rising number of newborns requiring intensive care. Federal analysts found that between 1996 and 2007, cesarean rates rose 36% for early preterm deliveries and almost 50% for late-preterm deliveries. Ultimately, babies most likely to be delivered surgically are therefore also among those most likely to need intensive care. And a baby born in 2024 was 96% more likely to be surgically delivered than one born in 1980.
That’s the national picture, but birth safety issues are far worse in some states than in others.
State Birth Safety By Decade
Across five decades and five measures of birth safety, the United States has improved in one area and deteriorated across numerous others.
The one inarguable success story involves infant mortality. A baby born in the 2020s is around half as likely to die before its first birthday as one born in the 1980s (5.52 compared to 10.86 deaths per 1,000 live births). The United States currently loses about 20,000 infants every year; in the 1980s, the figure was over 40,000.
While infant mortality levels have changed from the 1980s to the present day, the worst places for an infant to be born in the U.S. have remained consistent during that period.
The District of Columbia (DC) had the nation’s highest infant mortality rate in the 1980s (21.89 deaths per 1,000 live births), 1990s (17.21), and 2000s (11.73). Once DC rates improved, Mississippi became the deadliest state for infants in both the 2010s (8.96) and 2020s (9.03).
Beyond lower infant mortality rates, the share of babies born with a low birthweight has risen for five straight decades: from 6.84% in the 1980s to 8.48% in the 2020s. 2023’s 8.58% was the highest low birthweight birth rate ever recorded; overall, 50 of 51 jurisdictions feature worse figures than they did in the 1980s.
DC ranked highest for low birthweight babies in the 1980s (13.54%) and 1990s (13.95%). Since then, Mississippi has ranked highest in every decade: 11.60% in the 2000s, 11.74% in the 2010s, and 12.41% in the 2020s. A staggering one in eight Mississippi babies is born with a low birthweight, up 41% from the 1980s rate (8.81%).
A key factor is that, during the study period, how babies are delivered has significantly changed. Cesarean births almost doubled from 16.5% of deliveries in 1980 to 32.4% by 2024 (with the biggest increase taking place between 2000 and 2009). Rates of vaginal birth after cesarean fell from 28.3% in 1996 to 9.2% in 2004. And around one in three babies has been delivered surgically for 15 consecutive years.
New Jersey featured the highest cesarean rate in the 2000s (36.8%); during the 2010s it was Louisiana (38.3%); and in the 2020s it was Mississippi (38.2%).
How birth trends have changed has severely affected mothers as well as babies. Maternal mortality has nearly tripled: from 7.9 deaths per 100,000 live births in the 1980s, to 23.1 in the 2020s. The deadliest year of all was 2021, which featured 1,205 maternal deaths (32.9 per 100,000). (Note: part of this long-term rise reflects the addition of a pregnancy checkbox to death certificates between 2003 and 2017.)
DC had the highest maternal mortality rate during three consecutive decades (17.1 in the 1980s, 20.4 in the 1990s, and 36.6 in the 2000s). Alabama (14), Mississippi (12.9), and Wyoming (22.5) were the next-worst states during those three decades.
Louisiana was the top-ranking state during the 2010s (42.6), while Tennessee led the 2020s (41.8): in both cases, the rate amounted to over five times the 1980s national average. California (10.8) is the only large state that still features a rate similar to 1980s levels.
It’s worth pointing out that these changes are happening to a shrinking cohort. The general fertility rate fell from its 1990 peak (70.9) to a record-low in 2024 (53.8), a 24% decline. The 2020s are in line to feature the smallest birth numbers in over 40 years (3.63 million births a year).
Vermont featured the lowest fertility rate in the 1990s (50.3), 2000s (51.2), and 2020s (43.5); in the 2010s it was replaced at the top of the rankings by New Hampshire (50.5). Former boom states California, Nevada, Arizona, and Utah now feature fertility rates between 27% and 35% lower than their 1995 numbers.
When we look at the worst 10 states for birth safety between 2020 and 2024, Mississippi ranks highest, ahead of Louisiana and Alabama. Mississippi is currently the worst U.S. state for infant mortality, low birthweight and cesarean delivery, and third-worst for maternal mortality. Louisiana and Alabama rank second and third due to persistently poor scores across all four birth measures, with the likes of Arkansas and Georgia close behind. The same Deep South group dominated the infant mortality and low birthweight rankings during the 1980s.
In terms of surviving the first year, being born in America is statistically much safer now than it was in 1980. Yet when we consider the matter of healthy birthweight, maternal mortality, and how often babies are delivered surgically, it’s no safer now (and in most cases is less safe) than it was decades ago. And in many cases, child and mother safety depends more on their geographical state than it does on the decade in question.
Infant Survival Gains in Context
During the study period, the states that improved the most in terms of infant mortality were often those with the worst initial rates. For example, DC cut its infant mortality rate by 72% (from 21.89 deaths per 1,000 births in the 1980s to 6.08 by the 2020s), which represented by far the largest improvement in the country.
Rates also fell in New Jersey, by 66% (10.57 to 3.64): New York 64% (11.28 to 4.10), New Hampshire 61% (9.10 to 3.55), and Massachusetts 61% (8.81 to 3.45), rounded out the top five. Massachusetts and New Hampshire now feature some of the country’s lowest infant mortality rates.
California is the standout among large states, having cut its rate by a huge 57% (from 9.42 to 4.08) while delivering more babies than any other state. Illinois made the largest improvement among Midwest states (down 55%, from 12.54 to 5.67). Overall, 22 states beat the national 49% improvement, with eight of the ten biggest gains concentrated in the Northeast and West Coast.
In the main, the states that improved the least fill out the bottom of the rankings. Arkansas cut its rate by only 27% (from 10.94 to 8.03, the smallest national improvement) followed by South Dakota, Ohio, Oklahoma, Mississippi, and Maine, all of which saw improvements below 40%.
Mississippi rates improved 36% (from 14.17 to 9.03), yet it still features the country’s highest infant mortality rate, which is worse than the 1990s national average and worse than rates that New Jersey, New York, and DC had already managed by the 2000s.
While children in America are born to a racially diverse range of mothers, birth safety levels are far from uniform.
Race and Birth Safety Across The Decades
While White mothers delivered 80.5% of American babies in the 1980s, that share fell to 73.7% by the 2020s. Asian births now account for 6.3%, Native Hawaiian and Pacific Islander births represent 0.4%, and 417,360 babies born since 2020 (2.9% of all births) were recorded as being of more than one race, a category absent from older data.
Black birth rates have remained remarkably stable over the same period: 15.8% of births in both the 1980s and today (between 5.9 and 6.4 million births per decade). And while Black infant mortality improved 48% (from 19.60 deaths per 1,000 live births in the 1980s to 10.27 by the 2020s), White infant mortality improved at a faster rate (from 9.27 to 4.59).
Overall, the gap widened, with Black infants dying at 2.11 times the rate of White infants in the 1980s, and 2.24 times the rate in the 2020s.
To illustrate: a Black baby born in the 2020s suffers a higher chance of death than a White baby born in the 1980s. The comparative cost isn’t just hypothetical: from 1980 to 2024, 217,101 Black infants died who would have survived had they enjoyed the same mortality rate as White babies.
Birthweight factors emphasize the disparity. Rates of Black low birthweight rose from 12.85% in the 1980s to 14.6% by the 2020s, the highest rate recorded for any group. More than one in seven Black babies is now born below a weight of 5 pounds 8 ounces.
All racial groups were subject to a rise in the low birthweight rate. For White babies, the rate of low birthweight rose from 5.61% to 7.01%. The rise was steepest for American Indian and Alaska Native babies (who account for about 1% of U.S. births), up from 6.04% to 8.37%. For Hispanic babies, the rate rose from 6.18% to 7.75%.
One important contradiction persists: Asian infants are now subject to the country’s lowest infant mortality rate (3.71 per 1,000); yet the rate of Asian low birthweight is 9.15%, well above the White rate (7.01%). So, Asian babies are among the smallest at birth but are also the most likely to survive, which confirms that birthweight and survival rates are not necessarily linked.
For mothers, the racial gap is equally stark.
Black maternal mortality rose from 19.7 deaths per 100,000 in the 1980s to 51.9 by the 2020s. While White maternal mortality more than tripled (from 5.6 to 19.5), there’s still a huge gulf.
The long-term increase partly reflects changes in how pregnancy was reported on death certificates between 2003 and 2017, which enhanced levels of detection for every group. Nonetheless, the disparity was notable before any such changes.
American Indian and Alaska Native maternal mortality more than doubled (from 23.7 in the 2000s to 51.8 in the 2020s), almost tying Black mothers for the nation’s worst rate. Asian mothers (12.8) and mothers of more than one race (14.6) were both subject to numbers below the White rate.
Overall, two key aspects emerge. Gains in infant survival were broadly similar in percentage terms, so existing racial disparities continued. Yet losses in birthweight and maternal survival were unevenly distributed, with Black and Native families disproportionately suffering.
While measuring the human cost of birth in America is complex, the rising financial burden is relatively clear-cut.
Rising Birth Costs and Insurance Factors
The price of being born in America has rapidly risen.
In terms of costs in the 1980s, the only reliable national figure is that provided by the Health Insurance Association of America’s January 1986 survey, which tells us that an uncomplicated hospital delivery cost $2,560, while a cesarean was $4,270. If we adjust those figures for inflation, in 2024, that’s $7,327 and $12,222.
By the 2000s, federal hospital data was available. According to that data from 2003, the average childbirth hospitalization charge was $8,300. For an uncomplicated vaginal delivery, the cost was $6,200; for an uncomplicated cesarean, it was $11,500. Overall, childbirth accounted for over $33 billion in annual hospital charges.
In 2024 dollars, those respective figures come to $14,151, $10,570, and $19,606, meaning the real cost of a vaginal delivery rose around 44% between the mid-1980s and 2003.
By the 2020s, costs had roughly doubled yet again. Analysis for the 2021-23 period found that people with large employer coverage claimed $20,416 for pregnancy, childbirth, and postpartum care. By this point, the costs were $15,712 for vaginal delivery and $28,998 for cesarean, including $2,743 out of pocket.
The rise in costs is clear: a vaginal delivery rose from $2,560 to $15,712, a sixfold increase. Even after inflation, the real cost more than doubled. The out-of-pocket figure is especially significant: the $2,743 an insured family now pays is more than how much a delivery cost in 1986 (before inflation).
Medicaid
Roughly two in five American births are covered by Medicaid. Birth-certificate data confirms that Medicaid paid for 42.6% of births in 2016 and 40.2% in 2024, compared with private insurance (49.4% and 51.8%). Self-paid birth levels rose from 4.1% to 4.7%. In 2024, Medicaid financed 1,445,210 births.
That said, the payment source was not a feature of the U.S. birth certificate until 2003 and wasn’t reported by every state until 2016. So no federal figure exists for the Medicaid share of births in 1980.
The payer split heavily depends on geography and closely tracks the state results already covered. Louisiana features the highest Medicaid share (61.8%), followed by Mississippi (57.3%), New Mexico (54.7%), Oklahoma (51.3%), and Texas (48.8%). Utah features the lowest rate (19.7%), followed by New Hampshire (22.2%) and North Dakota (23.4%).
A state’s Medicaid share correlates to a 0.67 level with its low-birthweight rate and to a 0.5 rate regarding infant mortality. The ten states with the highest Medicaid shares average 9.5% low birthweight and 6.38 infant deaths per 1,000 births, compared to 7.45% and 4.75 among the ten states featuring the lowest shares.
The Payer Gap Starts Before Delivery
By comparing data by payer, we found a result that contradicts expectations: privately insured mothers have a higher cesarean rate than Medicaid mothers (33.5% versus 31.9%). That tells us that public coverage isn’t driving the increase in surgical deliveries.
Nonetheless, babies born on Medicaid are 37% more likely to be low birthweight (10.10% versus 7.39%) and 41% more likely to be very low birthweight. Those figures cover 7.4 million Medicaid births and 9.2 million privately insured births between 2020 and 2024.
The bottom line is stark: the real cost of giving birth has more than doubled since the 1980s. Additionally, Medicaid now covers around 40% of American births, and the states that most heavily rely on it have also ranked worst for infant mortality, low birthweight, and maternal death across the study period.
Premature birth rates are another persistent issue for American mothers.
Preterm Births: A Persistent Problem
In 1981, 9.4% of U.S. babies were born before 37 weeks. The rate climbed over the next quarter century, reaching 10.6% in 1990, 11.6% in 2000, and peaking at 12.8% in 2006, an overall rise of over 30%.
The parameters changed in 2014, when federal statisticians switched from a last-menstrual-period estimate to a clinical obstetric estimate, resetting the base premature birth rate at 9.57%. Since then, it’s risen almost every year. In 2024, 377,204 babies (10.41% of all births) were preterm (up 9% from the 2014 low and unchanged from 2023).
The composition of measurements is a key factor: early preterm births (births before 34 weeks) fell to 2.72% in 2024, the lowest level since 2020. However, late preterm births rose to 7.69%, a rise that drove much of the neonatal intensive care volume.
Birthweight reveals a similar trend: low birthweight was 8.52% in 2024 (above the modern low of 7.99% in 2012), while very low birthweight was 1.33%.
The burden is disproportionately shared. Between 2022 and 2024, 14.7% of Black infants were born preterm, compared to 9.3% of Asian and Pacific Islander infants and 9.5% of White infants. A Black baby was therefore roughly 1.6 times as likely to start life prematurely as a White baby.
The proportion of babies who need neonatal intensive care has also risen – another illustration of worsening birth conditions.
The NICU Has Become Routine
As of 2023, one in ten American babies (9.8%) needs neonatal intensive care (NICU), up from 8.7% in 2016. Among commercially insured births, the share of NICU or special-care nursery treatment rose from 17% in 2017 to 18.3% in 2021, almost one in five. Additionally, between 1991 and 2020, the number of neonatologists grew 227% (from 0.44 to 1.44 per 1,000 live births), while the number of NICU beds increased 48% (from 5.43 to 8.02 per 1,000).
During that time, neonatal mortality fell 43%, from 3.87 to 2.21 deaths per 1,000 births. Despite this, researchers found no meaningful correlation between extra capacity and improved survival, which suggests that the expansion was primarily a matter of reimbursement as opposed to clinical need.
In terms of admissions, the biggest increases didn’t involve the sickest babies: instead, admissions of normal-birthweight babies rose 16%, and 15% for early-term babies. Preterm admissions saw a small rise, from 49.1% to 51.6%.
There was significant state variation for preterm births: from 4.6% in Rhode Island to 14.2% in Delaware. Over a seven year period, notable rises were recorded in Mississippi (37%), New Hampshire (34%), and Alabama (32%), while Rhode Island’s low rate was partially due to a 31% drop in cases.
The Bill Follows the Baby
NICU costs are sizable. Commercial claims data suggests that the average stay in the NICU costs $71,158 (over an average of 14 days). The costs rise for the median use of level IV care: $128,000, or $3,741 a day.
And the overall costs are staggering. A year of preterm births costs U.S. society $25.2 billion ($64,815 per preterm infant). Since 2005, the per-infant cost has risen from $51,600; the fact that the aggregate total fell from $26.2 billion is slightly deceptive as fewer babies are being born.
Of the $25.2 billion, $17.1 billion represents medical care, $4.8 billion lost labor productivity, $2 billion maternal delivery costs, and $1.3 billion early intervention and special education.
With preterm births, the earlier the birth, the more extensive the eventual costs: $344,355 for a baby born before 28 weeks, $186,731 for a baby born at 28-31 weeks, and $28,367 for a baby born at 32-36 weeks. The majority of the money is spent after the child is born (in neonatal care and over the child’s lifetime) as opposed to in the delivery room.
American Birth Safety: Some Improvements, Many Enduring Inequalities
While fewer babies are born in America today compared to the 1980s, those who are born are more likely to be born early, of low birthweight, and following a surgical delivery; additionally, their mothers face more risk.
The extent of all those factors (and their associated costs) depends on the mother’s race, state of residence, and insurance status. Deep South states and Black and Native families continue to bear the heaviest burden.
On the plus side, infant mortality has massively improved since 1980. But while America is much better today at keeping babies alive, birth itself is no safer, with geography, race, and socioeconomic factors still key differentiators.
The birth of a child is a miraculous event. However, when something goes wrong, it can turn your family upside down and cause you immeasurable pain. When a preventable mistake injures your newborn, the future you envisioned for your child can quickly vanish. You may also become understandably overwhelmed by bills and caretaking duties.
The nationally recognized birth injury attorney team at the Birth Injury Lawyers Group dedicates its time to help parents of injured children fight for their rights. We offer hope and possible financial compensation to families harmed by a medical professional’s mistake.