Women in the South are more likely to die from cancer and during pregnancy than anywhere else in the U.S., according to a report by the nonprofit healthcare researcher Commonwealth Fund. Researchers found that health outcomes were tied to income and where a person lives.

The report found that access to care and quality vary widely across states, with the best women’s and reproductive healthcare offered in Massachusetts, Vermont and Rhode Island — states that have expanded access to Medicaid. Health services were ranked worst in places like Mississippi, Texas and Oklahoma, where women’s reproductive rights are restricted.

“Looking across states and comparing their health care systems is an important way of telling us what is and isn’t working in American health care,” Sara R. Collins, lead study author and Commonwealth Fund vice president for health care coverage and access, said in a statement. “(It) underscores the urgent need for federal and state policies to expand women’s access to affordable, timely reproductive care and other essential health services, regardless of who they are, what they earn or where they live.”

Researchers said supporting and expanding Medicaid is vital for reproductive rights, with the program covering about 42 percent of all births in the country and about two-thirds of care for Black and American Indian and Alaska Native mothers. They were also less likely to have insurance before giving birth.

According to the report, deaths from all causes among women of reproductive age — 15 to 44 — were highest in southern states. This includes deaths during pregnancy and other preventable illnesses like breast or cervical cancer, substance abuse, COVID-19 and treatable chronic conditions.

The maternal mortality rate nearly doubled between 2018 and 2022, with deaths increasing the most for Black and American Indian and Alaska Native (AIAN) women. The U.S. has a higher rate than other high-income countries, researchers said. Nearly two-thirds of pregnancy-related deaths occurred after delivery, according to the report.

The overturning of Roe v. Wade in June 2022 – which resulted in 21 states banning or restricting abortion – has deeply impacted reproductive health care access and how providers are able to treat pregnancy complications. Gaps in women’s health care are expected to widen, with people of color, low-income patients and thise who live in states with restrictions bearing the brunt.

Rates of maternal deaths were highest in Arkansas, Louisiana, Mississippi and Tennessee. These states had abortion restrictions and lower quality care before Roe was overturned. Florida’s six-week ban in April 2024 further devastated the South by limiting abortion access in the region. Liberal states like Vermont, California, and Connecticut had the lowest rates, according to the report.

Researchers estimated that one-third of U.S. counties had little or no access to maternity care in the wake of the 2022 court decision.

Nationally, Black and AIAN women were more likely to die during pregnancy. Mental health and substance abuse – including suicide and overdose – and cardiovascular conditions were the most frequently reported preventable causes of pregnancy-related deaths.

The report also found higher rates of women were uninsured in Texas, Georgia and Oklahoma. Many skipped necessary treatment because of cost. States with abortion restrictions like Alabama and Idaho had fewer maternity care doctors.

“It is disheartening to see the rising disparities in women’s health across the nation. Our

country’s fractured landscape of reproductive health access will make it even more difficult

to close these widening gaps,” said Dr. Laurie C. Zephyrin, the study co-author and Commonwealth Fund senior vice president for advancing health equity. “Instead of limiting care, federal and state policymakers should work to ensure that women have access to the full continuum of care throughout their lives.”

Citizenship status is also a determinator of quality health care. Undocumented migrants in the U.S. are barred from programs like Medicaid and often unable to pay exorbitant private fees for care. California, Colorado, Oregon and Washington are among the few states that use public funds to expand medical access for undocumented communities.